Thursday, April 25, 2013

Okay, people, time to see how good you are at being armchair neurologists.

This is an unusually challenging case I saw yesterday, involving a 54 year-old lady. Her internist had referred her to me because of some recent changes in her vision. The following is quoted verbatim from my chart note:

"She has 2 glasses prescriptions, one for near and another for distance. 1 month ago she had an annual optometry check-up, and was told she needed a new near-vision prescription. She ordered the new glasses, and picked them up last week.Since then she finds that when she puts on the new glasses things look “funny and unclear.” This resolves with taking them off, and doesn’t occur with the distance-glasses on, or using her previous prescription."

This case really has me stumped. So if any you are able to figure out what the problem is, please write in.

68 comments:

I'd say it could be a number of things, the lenses could be the wrong shape for the prescription (some must absolutely be round), there was a fault in production and the lenses are a different prescription or have warped, the pupilary distance was measured wrong, or one of the coatings was not applied correctly. My advice is to have the prescription of the lenses checked or not bother and have them redone.

Usually the eyes will adjust to faults in the lenses over time but because she uses 2 different prescriptions her eyes absolutely cannot adjust. This happened to someone I know her lenses made the world u-shaped and upside down and she didn't know until she had a new prescription because her eyes had adjusted.

If it's a problem with her eyes or brain I have no idea. These are just the things I can think of as a glasses wearer (and who most of these have happened to).

Not being funny, I assume the internist has a reason for the referal, but could it just be the new glasses? I have been wearing glasses all my life (too many years to admit), and whenever I get anew prescription, they give me a headache and make things look funny/ blurry for a few days until I get used to them.

Short-sighted internist and most people who have responded are presbyopic (they sound too serious to be joking!) TWO pairs of glasses, ONE for NEAR an ONE for DISTANCE. 'Near' won't work for distance and 'distance' won't work for near. Neither will work for both near and distance. Capiche?

The axis is off on one of the lens. I had the exact same symptoms and one lens was at .13° instead of 13° or something like those numbers. Easy check - close one eye and wiggle the frames on your face and see if you can find a spot where they work.

Although the reasoning behind two pairs (verse bi-focals) could also indicate a contributing factor.

While I am not sure, I do agree that the previous comments are the most obvious (horses, not zebras, eh?) Can you get the optho to check her glasses? They may be wrong. The new glasses seemed to start the trouble, but that could be coincidence. Other thought could be tumor in optic system but I am sure that was ruled out.Anyway, hope the pt is ok.

Sounds like a mix up in glasses, which is which. but I will tell you that I experienced blurry vision with new glasses and as it turned out my eyelashes would sweep the inside of the lense everytime I blinked, leaving an oil spot on the lense. No lie. No optho person figured it out for months. Finally I figured it out.

I'd say first referral should have been to lenscrafters to make sure the rx was prepared correctly. Also it's likely that because she is wearing two different pairs that her presbycutic (I may or may not have made up that word) eyes are having trouble adjusting to so many changes. She should probably just get bi/trifocals if she needs distance and near correction.

Well, I don't know, but I have a similar problem. Last November I was prescribed new distance lenses. When I put them on, thingslook weird--it is hard to describe, but I cannot see well when wearing them. The optometrists' office swears they are correct. I just gave up and went back to wearing my old glasses. I will ask the doctor to check them when I go back this year.

Given the number of comments it seems to have everyone stumped, How about near lens in one side far lens in other side. We will all be laying awake tonight mulling the problem and our collective vision will be blurry come morning. I hat that feeling of not knowing.

I have migraines of the "little stroke" severity and I cannot wear any of the bifocals. I have tried three lens "styles". Once I had a prescription error that caused everything to have a "break". i.e. Fences looked as it they were lying on the ground. Another time, they put the wrong + / - in one lens and I couldn't bear to look thru that one. I also have eyelashes that smear the lens. Print without a space blurs and I've never been able to read a license plate while driving. If the timeline started with the new glasses, that's most likely the problem but if not, I hope it is something minor and I think she is in good hands either way.

How was this chart note produced? In handwriting? If so, by whom? And was it written during sleep deprivation? If it was transcribed from a recording, was it done by a tired/underpaid/overworked medical transcriber? Was voice recognition software involved?

I'd want to double-check with the originator of the note before going further.

I don't have any answers, but can tell you that I have had glasses due to nearsightedness for 25 years, and always get fitted for my glasses and contacts at my opthalmologist's office. This this year, for the first time ever, I have had to go back and get the prescription corrected 3 times. And I still can't see as sharply as I used to. I finally gave up because the lens lady at the doctor's office basically told me the problem is me, not them.I do have rheumatoid arthritis and I wonder if that is what is causing my vision problems. I was tested for tear production and was told my eyes are not dry or anything, so I don't really know what's going on.

If this resolves with taking them off, that means she doesn't need correction eye glasses for near-vision. Her eyes still see well with the old prescription because they got used to adapt to that correction.

Unless she got a beginning of macular degeneration, but that would show on the distance-vision too.

Anon 6:39I am convinced that people with RA can't get a good rx for glasses. If inflammation levels affect vision, fluxuations in inflammation will lead to fluxuations in the amount of correction needed. That seems pretty obvious to diagnose, nearly impossible to fix. :(

Hey, wait, why is the internist involved anyways? I feel like this ought to be a discussion between the patient, her caregiver, the optometrist, the lenscrafter, and possibly a salesperson or two.

In fact, I feel like the neurologist makes more sense than an internist at this point. You could be asked to judge whether or not she understood what it was she was saying or remembering the difference between up and down. Plus, a visit to your office costs more, so therefore it must be worth more. QED.

When the same thing happened to me a different optometrist checked and realised the lens wasn't properly centred on the pupil on one side - only a fraction of a mm but enough. Luckily the lenses were large and he simply cut them down to fit smaller frames as spares - wasn't making much money as they were old frames he used. I'd used the glasses and just about got used to them but was never entirely happy. My daughter was talked into sunglasses with photochromic lenses for driving - except they were an older version and useless - with the same problem to boot. The same optometrist spotted they too were made incorrectly - the original company was a chain who would have lost their profit had they corrected the fault. He was a independent practitioner who cared about his clients - and was mostly cheaper than the other lot despite their claims.

We had a new onset headache referred to us once. The word "conversion" even came up.

Upon closer questioning, kid's been sick a week with a nasty virus and gastro, as was the rest of the family. Never had headaches before, so he didn't know what was going on. We reassured him he'll feel better when the virus resolves.

History is important.

For those trying to answer seriously, and perhaps not familiar with sarcasm, the actual answer is "the internist did not take a proper history, and made an inappropriate referral."

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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